Multiple Pregnancy: Twins or More

Topic Overview

Is this topic for you?

This topic is for women who are pregnant with more than one baby. It focuses on the questions that are specific to multiple pregnancies. For information on what to expect during pregnancy, labor, and childbirth, see the topic Pregnancy.

What is a multiple pregnancy?

A multiple pregnancy means that a woman has two or more babies in her uterus. These babies can come from the same egg or from different eggs.

Babies that come from the same egg are called identical. This happens when one egg is fertilized by one sperm. The fertilized egg then splits into two or more embryos. Experts think that this happens by chance. It isn't related to your age, race, or family history.

If the babies you're carrying are identical, they:

• Are either all boys or all girls.
• All have the same blood type.
• Probably will have the same body type and the same color skin, hair, and eyes. But they won't always look exactly the same. They also won't have the same fingerprints.

Babies that come from different eggs are called fraternal. This happens when two or more eggs are fertilized by different sperm. Fraternal babies tend to run in families. This means that if anyone in your family has had fraternal babies, you're more likely to have them too.

If the babies you're carrying are fraternal, they:

• Can be both boys and girls.
• Can have different blood types.
• May look different from each other or may look the same, as some brothers and sisters do.

See a picture of identical and fraternal babies in the uterus .

What causes a multiple pregnancy?

If you take fertility drugs or have in vitro fertilization to help you get pregnant, you're more likely to have a multiple pregnancy.

Fertility drugs help your body make several eggs at a time. This increases the chance that more than one of your eggs will be fertilized.

In vitro fertilization is the most common kind of assisted reproductive technology used to help women get pregnant. Several of your eggs are mixed with sperm in a lab. When the eggs are fertilized, they're put back inside your uterus. The doctor puts in several fertilized eggs to increase your chances of having a baby. But this also makes a multiple pregnancy more likely.

You're also more likely to have more than one baby at a time if:

• You're age 35 or older.
• You're of African descent.
• You've had fraternal babies before.
• Anyone on your mom's side of the family has had fraternal babies.
• You've just stopped using birth control pills.

What are the risks of a multiple pregnancy?

Any pregnancy has risks. But the chance of having serious problems increases with each baby you carry at a time.

If you're pregnant with more than one baby, you're more likely to:

• Develop a problem that causes your blood pressure to get too high (preeclampsia).
• Develop a type of diabetes that can occur while you're pregnant (gestational diabetes).
• Deliver your babies too early. When babies are born too early, their organs haven't had a chance to fully form. This can cause serious lung, brain, heart, and eye problems.
• Have a miscarriage. This means that you may lose one or more of your babies.

There is also a greater chance that one or more of your babies may be born with a disease that is caused by a bad gene or group of genes. If you or anyone in your family has had a child with a disease that is linked to a gene change, let your doctor know. There are tests that you can have between 10 and 20 weeks of your pregnancy that can tell if your babies are at risk for certain genetic disorders or birth defects.

Keep in mind that these problems may or may not happen to you. Every day, women who are pregnant with more than one baby have healthy pregnancies and have healthy babies.

How can you tell if you're carrying more than one baby?

While you may feel like you're carrying more than one baby, only your doctor can say for sure. He or she will do a fetal ultrasound to find out. This test can give your doctor a clear picture of how many babies are in your uterus and how well they're doing.

If the test shows that you're carrying more than one baby, you'll need to have more ultrasounds during your pregnancy. Your doctor will use these tests to check for any signs of problems that your babies may have as they grow.

What type of treatment will you need?

If you're pregnant with more than one baby, you'll need to see your doctor more often than you would if you were having just one baby. This is because you and your babies have a greater chance of developing serious health problems.

Your doctor will do a physical exam at each visit. It's important that you go to every appointment. Your doctor may also do a fetal ultrasound, check your blood pressure, and test your blood and urine for any signs of problems. Early treatment can help you and your babies stay healthy.

You're having multiples. Now what?

The thought of having more than one baby may be scary, but it doesn't have to be. There are some simple things you can do to keep you and your babies healthy.

The best thing you can do is take care of yourself. The healthier you are, the healthier your babies will be.

While you're pregnant, be sure to:

• Go to every doctor's appointment.
• Eat a healthy diet. Take in plenty of calories from foods rich in folic acid, iron, and calcium. These nutrients are essential for the healthy growth of your babies. Breads, cereals, meats, milk, cheeses, fruits, and vegetables are all good choices. If you're not able to eat enough because of severe morning sickness, call your doctor.
• Don't smoke, drink alcohol, or use illegal drugs.
• Avoid caffeine.
• Avoid using any medicines, vitamins, or herbs unless your doctor says it's okay.
• Talk to your doctor about what activities are okay for you to do while you're pregnant.
• Get a lot of rest.

After your babies are born, you may feel overwhelmed and tired. You may wonder how you're going to do it all. This is normal. Most new moms feel this way at one time or another.

Here are some things you can do to ease the stress:

• Ask your family and friends for help.
• Rest as often as you can.
• Join a support group for moms with multiples. This is a great place to share your concerns and hear how other moms cope with the demands of raising multiples.
• If you feel sad or depressed for more than 2 weeks, call your doctor.

Frequently Asked Questions

Health Tools

Health Tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I consider a multifetal pregnancy reduction?
	Actionsets are designed to help people take an active role in managing a health condition.
	Depression: Managing postpartum depression
	Pregnancy: Dealing with morning sickness

Symptoms

If you are pregnant with more than one fetus, you can expect to have the same symptoms as those of a pregnancy with one fetus (called a singleton pregnancy). But the symptoms may happen earlier and may be worse. A multiple pregnancy is likely to cause:

• Early and excessive nausea and vomiting in the first trimester.
• Extra weight gain.
• Backache.
• A uterus that is larger than expected for your due date.
• More fetal movement than expected during the second trimester and later.

Pregnancy: Dealing with morning sickness

Later in the pregnancy, you are more likely to have:

• Varicose veins.
• Constipation.
• Hemorrhoids.
• Increasing backache.
• Difficulty breathing (caused by pressure on the lungs from the uterus pushing up on the diaphragm).
• Indigestion (caused by pressure on the stomach from the large uterus).
• A very large abdomen.
• Gestational diabetes.
• Preeclampsia, a serious disorder of circulation and blood pressure that affects both mother and fetuses.
• Preterm labor.

Exams and Tests

In years past, women often had no idea that they were carrying twins until the end of pregnancy or the actual childbirth. Since the development of better tests, most multiple pregnancies are now identified during the first or second trimester.

A fetal ultrasound can show whether there is more than one fetus in the uterus. If you have more than one fetus, you will have an ultrasound several times during the pregnancy to monitor fetal growth and amniotic fluid.

Sometimes, the first sign of a multiple pregnancy is from a test that was done for another reason. For example, a very high level of human chorionic gonadotropin (hCG), the 'pregnancy test' hormone, can be a sign of multiple pregnancy.

Tests used to check for genetic disorders and birth defects

Fetuses in multiple pregnancies have an increased risk of genetic disorders and birth defects.

Test options include:

• Chorionic villus sampling (CVS). It uses a tiny piece of the placenta, taken by passing a thin tube through your vagina and cervix and into the uterus. The sampling and genetic testing are done between 10 and 12 weeks of pregnancy.
• Amniocentesis, which uses a small amount of amniotic fluid, taken by inserting a needle into your abdomen and uterus. The sampling and genetic testing are usually done between 15 and 20 weeks of pregnancy. (Amniocentesis is also sometimes used in the last trimester to see whether the fetuses' lungs are mature enough to breathe well after delivery.)

CVS and amniocentesis have the same slight miscarriage risk when used to test a multiple pregnancy. (For a pregnancy with one fetus, the CVS risk is a little higher.)¹ You may want earlier CVS results if you have to make decisions about treating or continuing a pregnancy.

Tests used to monitor the fetuses and mother during a multiple pregnancy

• Blood pressure checks at every prenatal appointment are used to monitor you for high blood pressure or preeclampsia.
• Blood testing is used to check you for low iron (anemia). Anemia is a common problem for women with multiple pregnancy, because the fetuses use a great amount of the mother's iron stores.
• A urine test and urine culture can be used to screen you for a urinary tract infection (UTI).
• Transvaginal ultrasound may be used to check the length of your cervix. A short cervix is a sign of an increased risk of preterm labor.
• In the second trimester, you may have an oral glucose screen to check for gestational diabetes.
• Electronic fetal heart monitoring may be used before or during delivery, to make sure the fetuses are doing well.

Treatment Overview

It is always important to take extra good care of yourself when pregnant. When carrying twins or more (multiple pregnancy), be sure to eat a balanced and nutritious diet of quality calories, and make sure that you get enough calcium, iron, and folic acid.

You can expect to gain weight more quickly than you would with one fetus. With each additional fetus a woman carries, her range of weight gain will increase.

Your range of healthy weight gain will be different if you started your pregnancy underweight or overweight.

High-risk pregnancy care

If you are pregnant with twins or more, good prenatal care will help you and your health professional prevent and watch for problems. You will have more frequent checkups than you would for a pregnancy with one fetus.

Complications can develop at any time during and after a multiple pregnancy. These include medical complications that:

• Affect the mother and fetuses, such as miscarriage, preterm labor and/or preterm birth, preeclampsia, gestational diabetes, and serious placenta problems.
• Affect the fetuses before birth, such as vanishing twin syndrome, twin-to-twin transfusion, and a higher risk of disability and genetic disorders.
• Affect the newborns because of premature birth, such as lung, brain, heart, and eye problems.
• Result in long-term disability for the babies. These can include mental retardation, cerebral palsy, learning disabilities, blindness, or deafness. These are most likely among babies born before 28 weeks.

Because you are more likely to deliver early, be sure to plan ahead. Ask your health professional about making arrangements to deliver at a specially equipped hospital. Such a hospital has facilities for emergency cesarean delivery, as well as a neonatal intensive care unit (NICU).

Early pregnancy decisions about triplets or more

When there are three or more fetuses in the uterus, their risks of disability or death are higher with each additional fetus. If you are carrying triplets or more after infertility treatment, your doctor may offer the option of multifetal pregnancy reduction (MFPR) near the end of your first trimester. A successful MFPR increases the chances of healthy survival for the remaining fetuses and reduces risks to you. But MFPR sometimes leads to miscarriage.²

The decision to have a multifetal pregnancy reduction is difficult and traumatic. If you are faced with this decision, talk to your doctor about your personal risks from trying to carry multiple fetuses to term compared to the risks of choosing MFPR. Also consider discussing your decision with a counselor or spiritual advisor.

Should I have a multifetal pregnancy reduction?

Preterm labor is more common in a multiple pregnancy than in a pregnancy with one fetus. If you go into preterm labor and premature delivery is likely, your health professional may recommend taking one or more precautions, such as:

• Limiting your activity level.
• Staying in the hospital. This is often so that you can receive steroid medicine to help your babies' lungs develop faster. In some cases, tocolytic medicine is used in an attempt to delay preterm birth. You are closely watched if you are treated with a tocolytic medicine. Complications of some tocolytics, such as pulmonary edema, are more common when you are carrying twins or more.³

There is no evidence that bed rest and home labor monitoring can prevent premature labor.² But they still are sometimes done. Talk to your doctor about whether partial bed rest and reduced activity might work well for you. See the topic Preterm Labor for more information.

Possible pregnancy problems that can be more likely when carrying twins or more include:

• Preeclampsia and high blood pressure. Treatment depends on how severe your condition becomes. It may include medicine, bed rest, fetal monitoring, and early delivery. For more information, see the topic Preeclampsia and High Blood Pressure During Pregnancy.
• Problems with the placenta, such as placenta abruptio or placenta previa. For more information, see the topics Placenta Abruptio and Placenta Previa.
• Anemia, which is treated with iron-rich foods and iron supplements. If this doesn't help, you can be tested for other problems that can cause anemia.
• Too much amniotic fluid in the uterus (polyhydramnios). Treatment can include medicine and removal of amniotic fluid.
• Urinary tract infection (UTI), which is treated with antibiotics.
• Heavy blood loss after delivery (postpartum hemorrhage), which can require a blood transfusion.
• The need to deliver by cesarean section (C-section). This is usually the case when fetuses are not turned head-down in time for birth (breech or transverse fetus ).

Any pregnancy can have these complications, but there is more concern about them happening during a multiple pregnancy.

Fetal complications

Possible complications that can affect multiple fetuses during pregnancy include labor complications, the healthy growth of one twin and poor growth of the other twin, and birth defects.

Infant complications

Giving birth early, called premature birth, is common in multiple pregnancies. Premature newborns usually need care in a neonatal intensive care unit (NICU) until they are mature and well enough to go home.

When born too early, a premature infant's major organs are not fully developed. This can cause health problems. Although any premature infant has some increased risk of medical complications, those who are born before 32 weeks of pregnancy have a higher risk. This risk increases with each additional week of prematurity.

Long-term disability resulting from premature birth requires specialized care over time. For more information, see the topic Premature Infant.

Home Treatment

A multiple pregnancy can make morning sickness worse during the first months of pregnancy. You can treat your symptoms at home, unless you have become dehydrated or are not getting enough to eat because of vomiting.

Pregnancy: Dealing with morning sickness

Learn the signs of early labor. They include:

• Cramping similar to menstrual cramps.
• Abdominal cramps, possibly with diarrhea.
• Contractions of your uterus that don't go away, about 4 or more in 20 minutes or about 8 or more within 1 hour.
• Pressure in your lower back, especially if it comes and goes.
• An increase in your usual amount of vaginal discharge.

Call your health professional immediately if you have symptoms of early labor.

Call your health professional or go to the hospital if you begin bleeding from the vagina or if your water breaks.

Self-care for multiple pregnancy

If you are pregnant with twins or more, you will be advised to:

• Make sure that you are taking in enough nutritious calories, folic acid, iron, and calcium to nourish you and your fetuses.
• Avoid alcohol, smoking, caffeine, most medicines, chemicals, X-rays, some cosmetic products, getting too hot, and eating contaminated food. All of these precautions are advised for any pregnancy. For more information, see the topic Pregnancy.
• Reduce your physical activity. Most doctors will recommend that you stop physically demanding exercise after 24 weeks of a multiple pregnancy. Talk to your doctor about walking or swimming.
• Get plenty of rest, especially after the 24th week of pregnancy. Studies show that strict bed rest does not prevent early (premature) delivery in multiple pregnancies.²
• Consider whether you need to change your daily work activities, based on how well your pregnancy is going. Be sure to follow any advice to reduce your activity level.
• See your health professional often. Beginning in the 20th week of pregnancy, you may be checked every other week. Beginning at the 30th week, you may be checked more often.

For more information on what to expect during pregnancy, labor, and childbirth, see the topic Pregnancy.

After the babies are born

Coping. Having a multiple pregnancy and caring for two or more infants at the same time can be overwhelming and exhausting. Lack of sleep, the increased amount of work, less personal time, and difficulty maintaining the home are common sources of frustration for parents of multiple infants.

With multiple newborns to care for, it is common to feel frustrated or guilty about not managing your life as easily as before. This is normal. Get extra help for as long as possible after your babies are born. Rest as often as you can during the day. Accept help from friends and family. They can bring meals, go grocery shopping, do household chores, or care for your children while you take some time for yourself.

Feeling sad or depressed (postpartum blues or postpartum depression) is more common after delivering twins or more.⁴ If you feel depressed for longer than 2 weeks or if you have troubling or dangerous thoughts, see your health professional. It is important that you get treatment. For more information, see the topic Postpartum Depression.

Depression: Managing postpartum depression

Consider joining a support group for parents of twins or more. Sharing your experience with other people who are in a similar situation may help you with the demands of caring for your babies. For more information, see the Other Places to Get Help section of this topic.

Breast-feeding? Breast-feeding more than one baby can be challenging, but it helps to build the bond between you and each baby. It gives your babies excellent health benefits. Breast-feeding also saves you hundreds of dollars that you would otherwise spend on baby formula. If you plan to breast-feed your babies, seek out support and information from your health professional, the hospital, or a lactation consultant before and after the birth. For more information, see the Other Places to Get Help section of this topic and the topics Breast-Feeding and Bottle-Feeding.

Parenting. Look for your new babies' personality differences and help them build their own identities over time. Give each of your children time alone with you. If you have an older child or children, schedule regular individual time with them.

Loss and grieving

Multiple pregnancy increases the risk of fetal death. Whether early in pregnancy or after birth, if one or more of your infants die, you and your family will need time to grieve.

Your hospital can help you contact support groups for grieving parents. Talking about your loss with friends, a spiritual advisor, or a counselor may also help. For more information on grief support, see the Other Places to Get Help section of this topic and the topic Grief and Grieving.

Other Places To Get Help

Organizations

Related Information

• Alcohol Effects on a Fetus
• Bottle-Feeding
• Breast-Feeding
• Breech Position and Breech Birth
• Cesarean Section
• Genetic Test
• Gestational Diabetes
• Growth and Development, Newborn
• Placenta Abruptio
• Placenta Previa
• Postpartum Depression
• Preeclampsia and High Blood Pressure During Pregnancy
• Pregnancy
• Premature Infant
• Preterm Labor

References

Citations

1. Malone FD, D'Alton ME (2004). Multiple gestation: Clinical characteristics and management. In RK Creasy, R Resnik, eds., Maternal-Fetal Medicine: Principles and Practice, 5th ed., pp. 513-536. Philadelphia: Saunders.

2. American College of Obstetricians and Gynecologists (2004). Multiple gestation: Complicated twin, triplet, and high-order multifetal pregnancy. ACOG Practice Bulletin No. 56. Obstetrics and Gynecology, 104(4): 869-863.

3. Newman RB (2003). Multiple gestation. In JR Scott et al., eds., Danforth's Obstetrics and Gynecology, 9th ed., pp. 225-245. Philadelphia: Lippincott Williams and Wilkins.

4. Bryan E (2003). The impact of multiple preterm births on the family. British Journal of Obstetrics and Gynecology, 110(Suppl 20): 24-28.

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